Application for Employment

 * Required Fields

9/8/2010

 Personal Information

Name(First, Middle, Last):*

SSN:*  

Best time to be reached: 

Address:* 

City:*
 

State:*

Zip:*  
 

Phone Number:*
 

Alternate Number:
 
Gender

 Email

 

 Referral Source
If referred by an employee, please state name and area:
If referred by an agency, please state agency name:

 Position Desired
Position:

Some positions might require working overtime, weekends, evenings, or holidays, is this acceptable?

Minimum Acceptable Pay :
$
 
Per
Date Available: 

 Eligibility/History
Are you eligible to work in the United States?
Are you at least 18 or older?
Have you ever been convicted of a crime?
If yes, please explain:   
Have you ever been excluded, debarred, suspended, or otherwise determined to be ineligible to participate as a provider or employee or agent of a provider of health care services associated with any federal, state, local, or private health care insurance program (for example, Medicare or Medicaid)?
Have you ever been convicted of, plead to contest to or been the beneficiary of a plea agreement involving a criminal offense charged against you related to health care?
Have you ever been employed by Rural/Metro or any of its subsidiaries?

Please list any relatives in our employ and relationship.  
Do you have a contract or agreement with another company that may limit your ability to perform work for Rural/Metro (e.g., a non-compete or confidentiality agreement)?

 Qualifications

Type of training

Expiration Date
(if any)

Level

Instructing Agency
(if any)

 Certification #
(if any)

EMT

CPR

 

 

 

 

other

 

 

 

 

 Employment Record (Please list 3 employers, most current first. We will be contacting supervisors for references.)

Company Name:

Supervisor's name:

Phone:  

Address:

City:

State:

Zip:  

Job Title:

Work Performed:

Reasons for Leaving:

Dates of Employment    
From
To
  
Salary Start 
$ 		End  
$
PER
May we contact this employer?

Company Name:

Supervisor's name:

Phone:  

Address:

City:

State:

Zip:  
 

Job Title:

Work Performed:

Reasons for Leaving:

Dates of Employment    
From
To
Salary Start  
$   		End  
$
PER
May we contact this employer?

Company Name:

Supervisor's name:

Phone:  

Address:

City:

State:

Zip:  
 

Job Title:

Work Performed:

Reasons for Leaving:

Dates of Employment    
From
To
Salary Start  
$   		End  
$  
PER
May we contact this employer?

 Education - High School

Name:

Location:

Last year completed:
Graduated:

 Education - College/University

Name:

Location:

Last year completed:
Graduated:

 Education - Graduate School

Name:

Location:

Last year completed:
Graduated:

 Professional Courses, etc.

Professional Courses  
 

Special Skills, Trade, Specialized Training, Apprenticeship, Extracurricular Activities  

 Equal Employment Opportunity (EEO)

To better evaluate the effects of our selection process and to enable us to meet government reporting requirements, applicants for positions at Rural/Metro are asked to complete this information. Your cooperation is voluntary and will be appreciated. Refusal to provide this data will not subject you to any adverse treatment. Any information you do provide will be treated as confidential personnel information and will only be used in accordance with applicable federal laws and regulations. 
 

RACE ETHNIC

Federal Tax Credit Eligibility Screening

This section is used to determine if your potential employer may be eligible for income tax benefits. Completion of this form is voluntary and may assist members of targeted groups in securing employment. Please read the following statements, then check the appropriate box.

  1. I am under the age of 25 AND I have not attended a high school, technical school or college for more than 10 hours per week or been regularly employed in the last 6 months
  2. I was unemployed or i worked less than 40 hours during the previous 60 days
  3. I am a Veteran of the U. S. Armed Forces AND EITHER
    1. A member of a family that received Food Stamps in 3 of the last 15 months
    2. a veteran entitled to compensation for a service-connected disability, or
    3. unemployed for at least 6 of the last 12 months
  4. I am a member of a family that received Food Stamps for the last six months (or al least 3 of the last 5 months and we are no longer receiving them)
  5. I was referred to an employer by a Vocational Rehabilitation Agency approved by a State, the Department of Veterans Affairs or an Employment Network under the Ticket 10 Work Program.
  6. I am a member of a family that received TANF assistance
    1. for any 9 months during the 18 months before I was hired,
    2. for at least the last 18 months before I was hired, or
    3. my family slopped being eligible for TANF assistance within the last 2 years
  7. I was convicted of a felony or released from prison after a felony in the last 12 months.
  8. I received Supplemental Security Income (SSI) within the last 60 days.

Please check yes if any of Ihe above statements apply to you as of your date of application.


Acknowledgement of Receipt

Representatives of Rural/Metro Corporation may not enter into an employment agreement for a specified period of time without express written consent of the Company's Chief Executive Officer or his/her designee.

As part of the employment application process at Rural/Metro and for subsequent employment purposes (if you are hired), a consumer report may be obtained. This type of report is generally called a credit or background check and may include information on your credit standing and capacity, character, general reputation, personal characteristics or mode of living. In accordance with the Fair Credit Reporting Act, by signing below you authorize any reference, school, former employer or other person to disclose to Rural/Metro upon request any information to Rural/Metro. Any reports provided to Rural/Metro will not contain medical information.

The information provided in this Application for Employment is true and complete. Rural/Metro may disqualify me from consideration for employment or terminate my employment for any false or misleading statements or omissions in this Application, whenever they may be discovered.

Any offer of employment extended by Rural/Metro is expressly contingent upon: (1) acknowledging receipt of Rural/Metro's Employee Handbook, Person to Person Program, Corporate Compliance Handbook and HIPAA Handbook; (2) passing a pre-employment substance abuse test; and (3) a satisfactory consumer report. Certain positions may have additional pre-employment requirements, which will be discussed with you during the application process.

Rural/Metro Corporation and federal and state laws prohibit discrimination on the basis of race, color, religion, national origin, sex, age, or disability.

I have read and agree to the Acknowledgement of Receipt, and all information provided in this application is accurate and complete.




*Please click the submit button only once. It could take up to 3 minutes to complete your application. You will be transfered to a new page once your application is successfully submitted.